[00:00:00] Dr. Cifu: On today's episode of The Clinical Excellence Podcast, we have Layne Keating talking about medical training so far.
[00:00:12] Dr. Keating: Even at top stages of your career, like you will make mistakes and you will be wrong at times. So I think for people, if they're not able to kind of separate their personal value from making mistakes, I think it's hard for those people to... It's never going to feel comfortable and it feels like this personal threat to be in situations where they could be wrong.
[00:00:30] Dr. Cifu: We're back with another episode of The Clinical Excellence Podcast, sponsored by the Bucksbaum-Siegler Institute for Clinical Excellence. On this podcast, we speak to patients and doctors about all aspects of excellence in clinical medicine. Today we continue our series talking to people in various stages of medical training to hear about their experiences.
I'm Adam Cifu and today I'm joined by Layne Keating. Layne is currently an internal medicine chief resident at the University of Chicago. She completed her undergraduate degree at Tufts University and her MD at the Frank H. Netter MD School of Medicine at Quinnipiac University. Her clinical and academic interests include improving medical care and outcomes for underserved patient populations and improving the ICU care experience and recovery process.
Layne, thanks so much for joining me.
[00:01:30] Dr. Keating: Thanks for having me.
[00:01:32] Dr. Cifu: So, tell me a little bit about the present stage of your career, kind of where are you, what's your schedule like, and what are the next steps for you?
[00:01:39] Dr. Keating: Yeah, so I just finished internal medicine residency, which was three years of clinical training back in June.
I'm doing an extra year, a chief resident year, which is more like administrative, focusing on scheduling, you know, medical education, all the things that go into making a residency program run. So that is kind of more of a nine-to-five desk job that I have for this year. And then I'm currently applying for a pulmonary and critical care fellowship which will be a three to four-year fellowship, you know, more training before eventually hopefully being done with training and, you know, moving towards attendinghood.
[00:02:13] Dr. Cifu: When I think about chief years, I usually think about sort of compared to residency, taking another step in kind of clinical, you know, independence, running teams to a greater degree, and also you know, sort of an educational position, educational role. Is that still pretty much the case?
[00:02:32] Dr. Keating: Yeah, I think, you know, there's definitely some clinical time. We precept in clinic and we will, you know, rotate through our general medicine service in the hospital which is nice because I think it's forcing me to take on that attending role before I go back into training. So hopefully build some, you know, confidence in that regard but yeah, like you said, it's a lot of, you know, scheduling, logistics that goes into, you know, what is required to run a residency program. So that has been interesting to kind of learn and experience. You kind of know that someone must be doing work to make this happen, but you know, it's definitely interesting, you know, a peek behind the curtain in terms of what actually is required to like, make something like this run.
[00:03:11] Dr. Cifu: Got it. Are there things so far that you are, you know, as you're like looking forward to your career, experiences that you're having now that you feel like, "Boy, this is going to serve me really well." And maybe on the flip side, things that you're like, "Well, this is teaching me that I never want to do this again."
[00:03:30] Dr. Keating: I think definitely the amount of clinical time, like I love working with patients. I love being a doctor. So I think I am excited to get back, you know, into a more heavily clinical, you know, job, but I think thinking about, you know, what I want my career to look like, you know, within my specific specialty.
I know I want to stay in academic medicine. I really like medical education. So I think, you know, medical education and potentially program leadership opportunities down the line is something that I am, you know, seriously thinking about. You know, is this something I want, you know, to do kind of later on and make a career out of this?
[00:04:07] Dr. Cifu: It's neat because I often sort of think about the chief year as a little bit of, you know, a service position. Of course, it's a job, but you know, it is in service of both the program and the residents but it is really a neat time to sort of pull back, reflect a little bit, and you get to meet with and work with so many people whose jobs are quite different. It's probably useful in terms of planning, you know, later on.
[00:04:35] Dr. Keating: Yeah, I think it's, you know, in the first few weeks of us starting, I feel like a lot of the attendings that are in the institution that were chief residents at one point, you know, kept circling through the office to kind of check in and you know, share their words of wisdom. There's actually letters that get passed down between chief resident class to chief resident class, you know, from one chief resident that spent, you know, 16 weeks on Gens like while as chief resident to now, like our floor positions, I think the role has definitely changed a lot, but what I've heard from like different departments is like, okay, you know, the people that have been a chief resident at some point, 'cause they just bring a different level of experience or organization or just like a different approach to problem-solving. So I'm, you know, very excited to have this opportunity and definitely, you know, excited to see, you know, where I can bring these skills next.
[00:05:21] Dr. Cifu: That's really neat. So let's talk a little bit about training in internal medicine. You were just a resident now, as you say, you're kind of in leadership. So what was the job like? Was it what you expected, kind of coming out of medical school, beginning as an intern and then a resident?
[00:05:36] Dr. Keating: Yeah. I think like, everyone comes into residency with different levels of training. You know, they've carried X number of patients on their own. They've worked in different hospital settings. So I think everyone kind of comes in with a different experience. My experience, you know, I'd worked at a lot of... I was at a newer medical school. So I'd rotated through, you know, seven or eight different community hospitals for the most part during medical school. So I was less nervous about starting in a new institution and kind of getting adapted to that but I don't think there's really much you can do to be prepared for, you know, showing up on day one and having ten patients and having to come up with plans. And you know, you have all the support, but I think it's still... You know, I think so much of medicine is you just have to do it to be able to like, know how to do it afterwards.
[00:06:25] Dr. Cifu: It's funny. I always remember, you know, moving to the city that I trained at a week before and just kind of knocking around on my bicycle and seeing things and like going by the hospital and basically having a panic attack before, it's like, "Maybe I don't want to do this."
[00:06:38] Dr. Keating: Everyone's always asking us like, "What can I do to prepare?" And I'm like, "Sleep. Just like enjoy your personal life and then you'll show up on day one and then you'll just, you know, learn it on the go."
[00:06:49] Dr. Cifu: Have you already... I don't know how to ask this in a non-biased way. I always actually feel like there's some benefit to moving around in training mostly because you recognize that things are done differently in different places, and often there are lots of different ways to do things that smart people do, and it works just as well. And so you're a little bit less like, "Yeah, whatever, you can do it that way, that's fine." Do you think that's true? Because you have worked with people who maybe were here throughout their whole medical school time, or was it one other place and then moved here? Is that something you've noticed?
[00:07:30] Dr. Keating: Yeah, it's definitely something like thinking about like fellowship training, like we have so many amazing people at the University of Chicago but there is like... Sometimes it does feel like there is a very University of Chicago way of doing something. I think there is enough variability from attending to attending or you know, people that you're working with, like trying to sort out like what are those stylistic differences versus like you know, not evidence-based differences that actually impact patient care. I think that's something that you deal with a lot, you know, in all stages of training, both as an intern, as a senior, as a fellow, as an attending.
So I think there's enough variety, I think, within the same institution. And it's always nice when people come from other institutions and you get a chance to work with them and get exposed to, you know, this is the way that we talk about types of respiratory failure, but like not everyone does that. So I think it's like the thing I like about medicine. It's like you can... There's different styles and I think it is an art in some ways that you can do it a different way and still be like technically correct.
[00:08:31] Dr. Cifu: And it's probably good to recognize. I feel like a difficulty often in caring for patients and often something that's hard for patients, right, is that patients sense, you know, disagreement among the teams taking care of them. And very much it is what you say, is that there are different approaches to this. There's obviously no cookbook you can look this stuff up in. And maybe what's important is just the culture that people are actually able to say like, "Oh, yeah, let's listen to this. Let's hear that you can do it all sorts of ways. And we're going to figure out for this individual, what's the best way to do it."
[00:09:08] Dr. Keating: Yeah. I mean, honestly, thinking, you know, about your question before about starting residency, I feel like that was one of the biggest learning moments of residency is realizing there isn't always an answer or a way to do things. And I think you go from med school where you're very, you know, focused on, okay, the answer is B to this question. And then you get into the reality of like, "Oh, I'm actually taking care of these patients and deciding the plan. And like, I don't know what the answer is." And like, it's not possible to know the answer at all times.
[00:09:37] Dr. Cifu: That's probably a perfect transition into my next question, which is, you know, you're in sort of a fortunate place of going through this, being a whole lot closer to medical training than me, and being able to reflect a little bit on sort of, you know, what's gone well, what's gone poorly. What do you feel like seemed like it was going well, but then you had to do such a shift, you know, at a different point in your career that you're like, "Huh, maybe I could have been better prepared for this?" Does anything stand out to you?
[00:10:09] Dr. Keating: Yeah, I think, like, in terms of what I've really enjoyed about my training so far, and as I'm, like, looking towards, you know, fellowship programs, what I want to... You know, what is important to me for those programs to have as well is, like, you know, I think we toss around this word autonomy a lot. And, you know, we're switching a little bit more to talk about like graduated independence but I think, you know, for me, being able to come up with that plan and actually, you know, making that management decision that does have consequences, I think developing the confidence to do that is so much of what, you know, training is that... You know, through my training at this program, I feel like that was really a focus. You know, the expectation is that they're your patients, it's your responsibility to take care of them and you have all the support in the world in terms of your attending and residents and fellows, you know, to make those decisions safely but if you're never forced to kind of be in that somewhat uncomfortable position of like having to actually make decisions, I think it makes that transition to leaving training so much more difficult.
[00:11:13] Dr. Cifu: Right.
[00:11:14] Dr. Keating: I think of things that, you know, now being on the other side of it and kind of getting to see, you know, I had my individual perspective in residency and experience, but now kind of as a chief, I'm getting to hear all these other people's experiences.
I think something that I think a lot about is kind of trainee wellness and burnout. And I just think the reality of what we do as a career and there'll be differing levels, depending on what field of medicine you're in, there's some parts about the job that are just unavoidably difficult and hard. You know, our patients are sick. Our patients sometimes die. There is that conflict sometimes or, you know, difficult conversations to have. So you know, if we shield trainees from that, I think we're unfairly, you know, preparing them for being able to handle those things but I think sometimes can be this, like, mentality of, you know, "Oh, well, those traumatic experiences make you tougher, or like, you need to grow a thick skin," that I think, you know, just acknowledging the fact that we do have a hard job. And especially as, you know, first-year or second-year trainees are experiencing those things for the first time, I think it can very easily feel like you're experiencing those things in like a silo and that, you know, "There must be something wrong with me if I'm having a tough emotional experience with dealing with these things."
[00:12:29] Dr. Cifu: I'm going to tie those together a little bit and, you know, absolutely feel free to argue with me and also feel free to like, you know, bow out and not say things you don't want to say but I do think that they're related a little bit in that being put in a position where the responsibility is maybe a little bit greater than you're ready for, right? Which is scary. And I think, as you said, it needs to be done in a way that's safe, so a good trainee at any level knows that, you know, he or she can sort of reach out for help when it's like, "Boy, I really don't know here. And I'm feeling the fear, I'm going to learn from this, but I can't do something which might, you know, risk my patient."
I do have a sense, and I'm going to talk about this especially in medical school, maybe more than residency, is because we have protected medical students so much from those positions now, that I think it's one of the reasons that getting to residency, sometimes it's even harder to sort of take on that responsibility. You know, grow into dealing with the stress, which you're right, is to some extent just inevitable when you're responsible for other people's well-being, right?
[00:13:49] Dr. Keating: I think the thing that, you know, what I've seen in myself that I view as strengths and what I've seen in other people that I think like they are able to, you know, do well and kind of like build that resiliency is that, you know, one, ability to ask for help and to kind of knowing what you don't know. I think for people that build a lot of like personal self-value in terms of always being right and are afraid to be wrong, there's so much about this career that like you never... You know, even at top stages of your career like, you will make mistakes and you will be wrong at times. So I think for people if they're not able to kind of separate their personal value from making mistakes, I think it's hard for those people to... It's never going to feel comfortable and it feels like this personal threat to be in situations where they could be wrong but you have to be wrong and you have to like... You know, there are some levels of like, acceptable mistakes that you have to make to be able to learn those skills to, you know, continue to advance in your career.
So I think, you know, we don't give people a lot of grace in terms of the grades they need to get or how well they need to do on tests to be able to get into medical school. So then it's hard to expect people to kind of switch to that growth mindset, I think, in medical school and in training to be able to not build all of this, like, personal self-value in terms of being right all the time.
[00:15:12] Dr. Cifu: Absolutely true. I mean, it is, by definition, a humbling career. And if you can't deal with the fact, I always say that, like, when I have a few of those weeks and I'm like, "God, I've really mastered this." I know that I'm up for just a total debacle that's going to make me feel like an idiot again. I think in the past, I'll put a link in the show notes about this, I read an article recently that had to do with kind of letters of recommendation. And the author made the point that in the past, one of the roles of medical schools was to take people who really wanted to be a doctor and could get into medical school, but if they weren't really right, that they wouldn't get through medical school, right? And "the not really being right" could be described in a bunch of different ways, but one of them maybe is what you're describing is the people who the job is going to be so painful for them and just make them chronically unhappy that they just be better off doing something else. And that you know, some will argue that our medical schools don't do that enough anymore, right? It's that if you got in and if, you know, you pay your tuition or somebody pays your tuition, you're going to get a degree almost no matter what and so the people who probably shouldn't be a doctor either for the good of the patients or the good of themselves, you know, kind of carry on and become somebody else's problem. And it may be the kind of grace you're talking about. Do you think there's a way earlier on in training to say like, you know, "Boy, you're terrific but let's try to figure out something that, you know, you'd be happier with over the course of your life."
[00:17:01] Dr. Keating: Yeah. I mean, I think it's a really hard question because I think, you know, coming I was first-gen college student. I was definitely first-generation in terms of medicine. So I think you get... You know, for someone who was interested in science and liked talking to people, medicine felt like an easy career. And I think it worked out really well for me. And I am really happy doing it and I can't see myself doing you know, anything else, but I think there's just like, so... You know, there are so many different types of jobs these days that it's... I think it can be hard, especially if you don't see anyone, or if you have parents that are doctors or this just feels like a very obvious... Like, this is a career I can be and you know, it's a pretty straight line from college to, you know, maybe you take a postbacc year, then med school, then, you know, there's all these steps lined out that if people are never given that opportunity to like, think about, like... You know, it's almost like by the time you realize this is not a happy career for you, you have all this sunk costs, literally, like financially, in time. And so I think it is like something that you know, obviously, there's a lot of other things people can do with an MD. So if they like realize that that's not what they want to do, you know, there's so many other career options and I don't think it's wasted, but I think it is, yeah, you know, trying to fit square pegs in a round hole in terms of, you know, you've done all this time while we're just going to kind of shuffle you through because it doesn't look good on the institution either if they don't necessarily have the same track record to uphold.
[00:18:28] Dr. Cifu: Right, and you may be right that what it takes is sort of building better off-ramps because often the least of the sunk costs is actually the financial ones, right? It's how committed you are and that for whatever six, eight years, you know, your entire imagination of what you're going to be, you know, is wrapped up in this, that it's very hard to change courses. And there is so much that one can do with an MD degree that maybe the appropriate thing is, you know, we've got you know, an MDR, you know, MD going to residency and an MD something else which is you know, you're a smart person, and this is what you're best cut out for, and we need well-trained people in those fields as well.
Well, this went completely off the subject of medical training. I guess maybe one last question. Are there, you know, in an ideal world, and man, you can speak to either medical school or residency, you know, are there things that you feel like you know, we should change, we could do better, we could reorient in some way? Like would you want the students coming into residency or the residents who now you're most directly caring for, you know, to be different or prepped differently before they meet, you know, Layne Keating, chief resident right now?
[00:19:56] Dr. Keating: I mean, I think I can only share like my personal experience of, you know, I did well in high school, got into a good college. I had a hard time during college for a variety of reasons. You know, I was working 30 hours a week, you know, way overcommitted in terms of was excited to learn. And, you know, GPA, not as good as I want it to be. So actually, I think I had a very hard time of getting into medical school.
And, you know, once I was able to get in and I think, you know, Quinnipiac being a newer medical school, I think really did a really good job of doing like holistic review and kind of taking more, accepting more of those like less traditional applicants but I knew like once I had that opportunity, like I would be able to be successful.
So I think there is... You know, it's medical schools only getting more and more competitive. And if you're going purely on academics alone, which obviously, you know, you need to be able to learn a lot of information to succeed in medical school and as a doctor but I think there can be improvements in terms of like how we you know, value people. I think we're trying to do this within residency of like, how do we assign value to certain aspects of people's applications of who would be, you know, good fit for our program. So I think, you know, looking at some of those like less traditional, like academic aspects of people's experience. Like I did like ten years of food service. And honestly, I think that most likely better prepared me for a career in medicine than any of my, you know, biochemistry classes at Tufts. So I think like thinking a little bit more critically and trying to be a little bit broader in terms of like how we like judge who is going to be successful in this career or not 'cause I think some of the knowledge things you can learn, but it's that like, how do you interact with patients? How do you interact with you know, interprofessional environments? How do you like multitask? Those things I think are a little bit, you know, I say as an internal medicine person, where all of those fields are, you know, very necessary, obviously different careers of medicine that, you know, there's certain things that are more important, but yeah. How do you like do more holistic review of like, you know, how people can bring expertise and value and you know, perspective to the career that isn't just like, you know, an MCAT score and GPA.
[00:22:16] Dr. Cifu: I couldn't agree with that enough. I think that for so long, because there were so many more applicants than there were spots, the easiest way to deal with it was to continuously raise the academic bar which did a good job of filtering people out, but didn't necessarily serve us with, you know, the best, you know, trainees, young doctors. I think the unfortunate thing is, and I agree completely with like everything you said, is that, you know, it probably costs more to do this sort of evaluation that you're asking for.
[00:22:51] Dr. Keating: Oh yeah, definitely more time too. Like to be able to like actually think critically requires time.
[00:22:57] Dr. Cifu: Absolutely, and I always go back to you know, what a 20-something who's, you know, applying into tech jobs have to go through to get their job, where it's multiple rounds of interviews and, you know, coding problems and things like that. And while we, you know, sort of look at a paper application and then have a 20-minute chat. And we're interviewing people for like, you know, take care of people's lives. That's really something.
So Layne, thank you so much for taking the time to sit down and talk with me, especially out of a busy schedule.
Thanks for joining us for this episode of The Clinical Excellence Podcast. We're sponsored by the Bucksbaum-Siegler Institute for Clinical Excellence at the University of Chicago. Please feel free to reach out to us with your thoughts and ideas via the Institute webpage. The music for The Clinical Excellence Podcast is courtesy of Dr. Maylyn Martinez.